Management of endogenous fungal endophthalmitis with voriconazole and caspofungin

PURPOSE: Voriconazole, a new generation triazolel has been shown to achieve therapeutic intraocular levels after oral administration. Caspofungin is the first approved agent from a new class of antifungals, the echinocandins. This series describes experience at two centers using these novel antifungals to treat endogenous fungal endophthalmitis. DESIGN: Retrospective review. METHODS: Treatment of five patients with Candida endophthalmitis are reviewed. Postmortem intraocular voriconazole concentrations on a sixth patient are presented as well. RESULTS: All patients had systemic cultures positive for Candida species. Three patients had prompt resolution of intraocular mycosis with intravenous and oral voriconazole, caspofungin, or both. The fourth patient with bilateral disease responded well to IV voricona-Zole and caspofungin but had a recurrence when discharged on oral voriconazole and IV caspofungin. This patient had a bowel resection with an ileostomy; therefore, absorption of oral voriconazole may have been inadequate. Bilateral amphotericin B intravitreal injection ultimately treated this patient. The fifth patient received 100 mug/0.1 ml of intravitreal voriconazole (final vitreous concentration approximately 25 mug/ml) followed by oral voriconazole and responded favorably. Our sixth patient had multisystem failure and passed away 1 week after initiating intravenous voriconazole for nonocular candidemia. Postmortem HPLC analysis of the aqueous and vitreous revealed voriconazole concentrations of 1.52 mug/ml and 1.12 mug/ml respectively (MIC90 of Candida albircans is 0.06 mug/ml). CONCLUSIONS: Voriconazole and caspofungin appear to be powerful weapons to add to the existing armamentarium against fungal endophthalmitis. Further studies are warranted to define precisely the role of these new agents alone or in combination with other antifunga. (C) 2005 by Elsevier Inc. All rights reserved.